Old Bridge Township EMS Employment Application

Old Bridge Township EMS, Inc.

Employment Application

Thank you for your interest in Old Bridge Township EMS.

Kindly take the time to READ and COMPLETE this employment application in its entirety.
Legible copies (front and back) of your certifications and driver's license need to be submitted at the time of your interview.

Motor vehicle driving record will be obtained for review during applicant processing. Additionally, any offer of employment with Old Bridge Township EMS will be contingent upon successful drug testing, skills and lift testing and an acceptable motor vehicle record.

Should you have any questions pertaining to the application process, please submit a General Purpose Contact Request Form that can be found on our home page.

Mandatory Items Are: (Name, Present Address, City, State, Zip, Phone, Age-21-Over, Email Address & Desired Salary) are marked with: **

Personal Information

Name (Last Name First) **

Social Security No. (optional here)

Present Address **

Apt#

City **

State **

Zip **

Permanent Address

Apt#

City

State

Zip

Phone **

Alt Phone

Best time to be reached

Are you 21 years or older? **
YES NO

Are you eligible to work in the United states?
YES NO

Have you ever been convicted of a Felony?
YES NO

If yes, explain (will not necessarily exclude you from consideration)

Email Address **

Date: June 28, 2017

Serial No. 1498682640

Desired Employment

Position	Date you can start	Desired Salary **
Some positions might require working overtime, weekends, evenings, and holidays. Is this acceptable? YES NO

Are you employed now? YES NO	If so may we inquire of your present employer? YES NO
Have you ever applied for OBTEMS before? YES NO	If so, when?
Have you ever worked for OBTEMS before? YES NO	If so, when?

Reason for Leaving

Name of last supervisor at OBTEMS

Who referred you to OBTEMS?
Employment Agency Newspaper Advertising Friend State Employment Office College Placement Service Walk In Other

Do you have any relatives employed by OBTEMS?
YES NO

If so what is their relationship to you?

Education - Must be 18 years old and have a high school diploma or GED

	Name and Location of School	Years Attended	Date Graduated	Fields of Study
Grammar School
High School
College
Trade, Business, or Correspondence School

Qualifications

EMT Certification	Certification No.	Expiration
CPR Certification	Certification No.	Expiration
DL Number	License No.	Expiration

Other Certification #1 (List if applicable)
Other Certification #2 (List if applicable)

Where did you take your EMT Class?

Instructor's Name

Former Employers (List below: last three employers, starting with the most recent)

Name of present or most recent employer

Address

City

State

Zip

Start Date	Leaving Date	Job Title
Weekly Starting Salary	Weekly Final Salary	May we contact your supervisor? YES NO

Name of Supervisor

Title

Phone

Description of work

Reason for Leaving

Name of previous employer

Address

City

State

Zip

Start Date	Leaving Date	Job Title
Weekly Starting Salary	Weekly Final Salary	May we contact your supervisor? YES NO

Name of Supervisor

Title

Phone

Description of work

Reason for Leaving

Name of other previous employer

Address

City

State

Zip

Start Date	Leaving Date	Job Title
Weekly Starting Salary	Weekly Final Salary	May we contact your supervisor? YES NO

Name of Supervisor

Title

Phone

Description of work

Reason for Leaving

References
(Below, give the names of three persons you are not related to whom you have known for at least one year)

Name	Address	Phone	Years Acquainted

Military Service Record

Branch of Service

Discharge Date

Rank

EEO Data (voluntary)

To better evaluate the effects of our selection process and to enable us to meet government reporting requirements, applicants for positions at Old Bridge Township EMS are asked to complete this information. Your cooperation is voluntary and will be appriciated. Refusal to provide this data will not subject you to any adverse treatment. Any Information you provide will be treated as confidential and will only be used in accordance with applicable federal laws and regulations.

Race Ethnic (choose only one)

White	Not of Hispanic origin. Person having origins in Europe, North Africa, or the Middle East.
Black	Persons having origins in the black racial groups of Africa as well as Jamaica, Trinidad, or the West Indies.
Asian/Pacific Islander	Persons having origins in the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, and Samoa.
Native American	American Indians; also Eskimos and Aleuts
Hispanic	Persons having origins in Mexico, Puerto Rico, Cuba, Central/South America, or other Spanish Cultures.

Sex	MALE FEMALE

	Authorization: I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this applications shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing or signed by an authorized company representative.
	By clicking Submit, I agree to the preceding statement. I am clicking the Submit button in lieu of placing my written signature on this application for the purpose of online submittal, and understand that I will be required to physically sign a hard-copy at the time of my interview. In an effort to curb spam and be sure you are a live person submitting this form: You MUST first enter the LAST 4 DIGITS of this application's Serial No. IN REVERSE, in the box below! Example: If your application Serial No. was 2399195271 then you would enter 1725 ~ Simple but necessary ~ Be sure you entered the digits in the box above! Failing to do so could make you start over again. !! PLEASE PRINT yourself a copy of this completed application BEFORE submitting in case you don't receive an emailed applicant copy. It is always best to be prepared for the unknown in our line of work !!